Based on interview and record review it was determined the facility failed to immediately notify the physician of a significant change in condition and head injury for 2 of 3 sampled residents (#s 1 and 3) reviewed for change in condition. This resulted in delayed treatment for Resident 3's significant change in condition and placed residents at risk for unmet needs and delayed treatment. Findings include: 1. Resident 3 was admitted to the facility in 2021 with diagnoses including dementia and partial paralysis. Resident 3's Progress Notes revealed the following: - On 5/23/23: Witness 4 (Physician) assessed Resident 3 related to the resident's family report of pain during a bowel movement. …
F580 citations in Oregon
Notifying of changes · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F580 less often than its own record predicts
0.56 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F580.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F580 findings written in Oregon, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, it was determined the facility failed to notify the resident representative of a potential accident for 1 of 3 sampled residents (#5) who were reviewed for elopement. This placed residents and responsible parties at risk for delayed notification. Findings include:Resident 5 was admitted to the facility in 7/2026 with diagnoses including dementia and anxiety. An 8/11/26 Nurse's Note indicated Resident 5 left the facility without notifying staff and was brought back to the facility by the fire department. Staff 2 (DNS) and the provider were notified of the incident. There was no documented evidence that Resident 5's representative was notified of the incident. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 1.17% | 0.81× |
| 2024 | 1.36% | 0.90× |
| 2025 | 0.84% | 0.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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